Objective:

To evaluate the effectiveness of decompressive hemicraniectomy compared to medical management in patients with malignant middle cerebral artery infarction through a systematic review and meta-analysis.

Approach:

• Data Sources: Comprehensive search of PubMed, Embase, and Cochrane Central Register of Controlled Trials from inception through February 18, 2023.

Key Findings:

• Decompressive hemicraniectomy significantly reduced mortality at 30 days (risk ratio: 0.26, 95% confidence interval: 0.16 to 0.50), 6 months (risk ratio: 0.43, 95% confidence interval: 0.12 to 0.57), and 12 months (risk ratio: 0.46, 95% confidence interval: 0.13 to 0.59).
• Favorable functional outcomes improved at 3 months (risk ratio: 1.86, 95% confidence interval: 1.31 to 2.63) and 6 months (risk ratio: 1.58, 95% confidence interval: 0.94 to 2.67) but not at 12 months.
• Survival with severe disability did not differ significantly between surgical and medical management groups at 6 or 12 months.
• Barthel Index scores showed significant improvement favoring surgery at 3 and 6 months.

Interpretation:

Limitations:

• Substantial heterogeneity observed in Barthel Index scores, which may affect the interpretation of functional outcomes.

Conclusion:

The meta-analysis provides insights into the sustained mortality benefit of decompressive hemicraniectomy and highlights the differences in functional outcomes based on age and follow-up duration.